Traction table versus manual traction in the intramedullary nailing of unstable intertrochanteric fractures: A prospective randomized trial

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Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury
Traction table versus manual traction in the intramedullary nailing
of unstable intertrochanteric fractures: A prospective randomized trial
Ercan Şahin a,*, Murat Songür a, Mahmut Kalem b, Sinan Zehir c, Mehmet Atıf Erol Aksekili d,
Selçuk Keser a, Ahmet Bayar a
a
Bülent Ecevit University, Faculty of Medicine, Department of Orthopedics& Traumatology, Zonguldak, Turkey
Ankara University, Faculty of Medicine, Department of Orthopedics& Traumatology, Ankara, Turkey
Hitit University, Faculty of Medicine, Department of Orthopedics& Traumatology, Çorum, Turkey
d
Yıldırım Beyazıt University, Faculty of Medicine, Department of Orthopedics& Traumatology, Ankara, Turkey
b
c
A R T I C L E I N F O
A B S T R A C T
Article history:
Accepted 12 April 2016
Introduction: The purpose of this prospective randomized study was to compare traction table with
manual traction for the reduction and nailing of unstable intertrochanteric femur fractures.
Design: Prospective, randomized, two-center trial.
Materials and methods: 72 elderly patients with AO/OTA 31A2 and 31A3 proximal femur fractures were
randomized to undergo surgery with either manual traction (MT) or traction table (TT) facilitated
intramedullary nailing. The demographics and fracture characteristics, duration of preparation and
surgery, total anaesthesia time, fluoroscopy time, blood loss, number of assistants, early post-operative
radiological evaluations and 6th month functional and radiological outcomes were evaluated. Data of 64
patients attending 6th month follow-up examination were evaluated statistically.
Results: No significant differences were observed between groups regarding demographics and fracture
characteristics. In the manual traction group, there was a significant time gain in respect of the
positioning and preparation period (18.0 1.6 min in MT group, 29.0 2.4 min in TT group) (p < 0.05). In
terms of total anaesthesia time (Preparation + surgery) approximately 6 min of difference was observed in
favor of MT group (72.8 14.0 min for MT and 78.6 6.5 min for TT, [p < 0.05]). Median number of
assistants needed was significantly lower in TT group (2 assistants [1–3]) in MT group and (1 assistant [1,2])
in TT group [p < 0.05]). There was no significant difference between two groups regarding other surgical and
outcome parameters.
Conclusions: Manual traction reduced the preparation time and total anaesthesia duration, despite an
increase in number of surgical assistant.
Level of evidence: Level II.
ß 2016 Elsevier Ltd. All rights reserved.
Keywords:
Intertrochanteric fracture
Traction
Surgery
Intramedullary nailing
Introduction
It is difficult to achieve and maintain reduction in unstable
intertrochanteric fractures, since the fracture line may have
extended into the trochanter minor and subtrochanteric region
and the posteromedial cortex may have been fragmented. These
fractures are generally seen in elderly patients with poor bone
stock and concomitant comorbidities. Ideal treatment is early
* Corresponding author at: Bülent Ecevit University, Faculty of Medicine,
Department of Orthopedics & Traumatology, P.B. 67100, Zonguldak, Turkey.
Tel.: +90 3722613055; fax: +90 5448998424.
E-mail address: dr_erc_sah@yahoo.com.tr (E. Şahin).
fixation with as little surgical trauma as possible and early
mobilization postoperatively. To reduce surgical morbidity to a
minimum, it is of great importance to restrict the period of
anaesthesia [1–4]. The currently preferred treatment method for
unstable trochanteric region fractures is indirect reduction and
Cephalomedullary nailing used as fixation, which is frequently
achieved by use of a traction table (fracture table) [5–9].
Traction tables are often used in the treatment of pathologies
around the hip (fracture, arthroscopic interventions, etc.) [10–12].
Aim of using a traction table can be summarized as; increasing the
quality of reduction and facilitating the application of the surgical
procedure to be able to be made with fewer assistants or by the
surgeon alone. In addition to the time taken to set up the traction
table and position the patient, complications may be seen
http://dx.doi.org/10.1016/j.injury.2016.04.012
0020–1383/ß 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Şahin E, et al. Traction table versus manual traction in the intramedullary nailing of unstable
intertrochanteric fractures: A prospective randomized trial. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.04.012
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2
associated with the traction table use, such as neurological injuries
(pudendal nerve palsy, sciatic nerve palsy, common peroneal nerve
palsy, erectile dysfunction), soft tissue contusions, pressure ulcers,
compartment syndrome, crush syndrome and vascular injuries
(by-pass graft occlusion, inferior epigastric artery avulsion)
[13–18]. Although these complications have been reported quite
rare in literature, the exact incidence is not known. Alternatively to
avoid these potential problems of traction table, traction can be
applied manually on supine position on a normal radiolucent table
by help of a surgical assistant for the reduction of fragments and
facilitating the intramedullary fixation.
The aim of this prospective randomized study was to compare
traction table facilitated intramedullary nailing with manual
traction facilitated intramedullary nailing of unstable intertrochanteric femur fractures.
Materials and methods
This study was carried out by approval and supervision of Local
Ethical Committee and a total of 72 patients were enrolled in the
study from one university hospital and one research and training
hospital. Inclusion criteria were defined as AO classification type
31A2 and 31A3 (unstable) proximal femur fractures of elderly
patients (age over 60) to undergo closed reduction and internal
fixation with intramedullary nail between January 2014 and
November 2014. Exclusion criteria were defined as; debilitated
patients without walking ability and capacity, additional fractures
or pathological fractures. Informed consent was obtained from the
patients or from a first degree relative in cases with dementia. The
patients were randomized with the permutation block randomization method for 36 patients to undergo surgery with manual
traction (MT) and 36 patients to undergo surgery with a traction
table (TT). The demographics and fracture characteristics including; gender, age, side, mechanism of injury, ASA (American Society
of Anesthesiologists) score, AO fracture type and pre-fracture
ambulation scores according to Palmer and Parker [19] were
recorded.
Surgery preparation
Manual Traction: The patients in the manual traction group
were placed in a supine position under anaesthesia on the
radiolucent table and the fluoroscope was positioned on the
opposite side to be able to comfortably show the fracture area.
After routine supine positioning, the hip was elevated 308 by
placing a folded compress under the sacrum of the same side and
leaving the lower extremities free. Then the routine skin
preparation and draping were performed. The fracture reduction
and preservation of the reduction was achieved with longitudinal
traction and manipulation with the aid of an assistant. The status
and quality of the fracture reduction were checked with the C-arm
fluoroscope in the anterior-posterior and lateral planes. To have a
clear lateral image, c-arm was passed from opposite side under
operation table and while passing to operation field, extra sterile
towels were used to avoid contamination. Since operated side was
elevated approximately 308 with a folded compress under sacrum,
superposition of uninvolved hip and handle of aiming device could
be avoided (Fig. 1a and c).
Traction Table: Anaesthesia was administered to the patient on
a gurney before transferring to the traction table. The patient was
positioned on the fracture table with perineal lateralization post on
the opposite side of the fracture site to prevent excessive
distraction of the joint. Both lower extremities were fixed to the
traction table with the foot apparatus. The contralateral extremity
was brought into abduction to allow the C-arm fluoroscopy device
to be positioned between legs for optimal AP and lateral view. The
fracture fragments were reduced with manipulation under
fluoroscopy control and the traction table was fixed into an
appropriate position by locking the connections. Occasionally,
extra manipulation is required to control position of fracture
Fig. 1. C-Arm setup for (a) anteroposterior and (c) lateral view for intramedullary nailing by manual traction applied by a surgical assistant. (b) Antero-posterior and (d) lateral
fluoroscopy images showing 1218 of neck-shaft angle. Therefore, quality of reduction was accepted as ‘‘good’’ in this case.
Please cite this article in press as: Şahin E, et al. Traction table versus manual traction in the intramedullary nailing of unstable
intertrochanteric fractures: A prospective randomized trial. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.04.012
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3
Fig. 2. (a) C-Arm setup and antero-posterior and (b,c) lateral images of intramedullary nailing facilitated by traction table. Note that abduction of contralateral hip is necessary
for introduction of C-arm between the legs. Neck-shaft angle was measured as 1348 with no shortening. Quality of reduction is accepted as ‘‘anatomic’’.
fragments. In such circumstances, an extra assistant was needed to
keep the fracture reduced. Then, similarly routine skin preparation
and draping were performed. (Fig. 2a)
15 and 25 mm. During insertion and after placement of the
implants, two plane fluoroscopy controls were made at each step
to ensure fracture reduction and proper implant positioning
(Figs. 1b and d and Fig. 2b and 2c).
Surgical intervention
Data collection
All operations were performed at two different centers by two
surgeons with at least 5 years of experience on hip and trauma
surgery. 18 20 cm. short InterTAN (Smith & Nephew, TN, USA)
nails with single distal locking were used for fixation in all patients.
Fractures necessitating long nails were not included in the study.
Spinal or general anaesthesia was applied. Routine prophylactic
antibiotics and pharmacological deep vein thrombosis prophylaxis
were administered.
Operation team included the operating surgeon and assistant
(or assistants). The number of assistants participating in surgery
was determined according to need (maintenance of reduction and
positioning). Occasionally, especially in obese and large habitus
cases or delayed fractures extra assistant was required in both MT
and TT cases. Number of assistants participating in the surgery was
also recorded. The nailing procedure was applied according to
standard surgical protocols. After fracture reduction and reaming
of the trochanteric entrance, the nail was placed without any
diaphyseal reaming procedure and then two screws (lag and
compression screws) were placed in the femoral neck. Intertrochanteric compression was applied and a locking screw was
placed from the distal. During the surgery, care was taken to keep
neck-shaft angle around 1308 and the Tip-Apex-Distance between
Duration of preparation (starting from completion of anaesthesia
to incision, including positioning and draping), duration of surgery
(incision to wound closure and dressing), fluoroscopy time (minutes
for each patient including reduction before preparation in TT group),
estimated blood loss (from sponges, aspiration tubes and drains),
and number of assistants were recorded. Total anaesthesia time
(period between completions of anaesthesia to transfer to recovery
room) was also calculated by sum of durations of preparation and
surgery for each patient. On post-operative day one, anteroposterior and lateral radiographs were taken and evaluated by a
radiologist for reduction and fixation quality. Reduction quality was
evaluated according to criteria defined in the study by Schipper et al.
The reduction was defined as anatomic (cortical continuity,
symmetrical neck shaft angle, no shortening, good (5 108 varus/
valgus) or poor (>108 varus/valgus) [20]. Fixation quality was
evaluated according to the position of the neck screw within the
femoral head according to the Cleveland and Bosworth quadrants
[21]. Postoperatively, the patients were encouraged to be mobilized
as soon as possible with a walking frame with partial weight-bearing
allowed for 6 weeks. At the end of six weeks, full weight-bearing was
permitted. 6th month follow-up examination included physical
Please cite this article in press as: Şahin E, et al. Traction table versus manual traction in the intramedullary nailing of unstable
intertrochanteric fractures: A prospective randomized trial. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.04.012
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examination, functional outcome interviews and radiographic
evaluations for evaluation of union. Malunion was accepted as
>108 of varus or valgus angulation and >10 mm shortening [22]. For
functional assessment, ambulation scores according to Palmer and
Parker [19] and Harris Hip Scores were calculated [23]. Postoperative complications seen in the follow-up period were also recorded.
Statistical analysis
Data of patients completing 6th month follow-up examination
were included for statistical evaluation. Statistical analysis of the
study data was performed with SPSS 19.0 software. Continuous
variables were stated as mean, standard deviation, median,
minimum and maximum values and categorical variables as
frequency and percentage. Conformity to normal distribution of
continuous variables was tested with the Shapiro Wilk test and in
the comparison of two independent groups; the Mann Whitney
U-test was used. In the comparison between groups of categorical
variables, the Pearson Chi-Square test, Yates Chi-Square test and
Fisher’s Exact Chi-Square test were used. In all the statistical
analyzes, p < 0.05 was accepted as statistical significance.
Fig. 3. Graph showing the difference between the duration of preparation.
Results
One patient from MT group was lost during surgery and seven
cases (five from MT group and two from TT group) did not attend
the recommended 6th month follow-up examination. Therefore,
the 6th month evaluation was completed with 64 patients,
constituting the study group. The demographics and fracture
characteristics including; sex, age, side, mechanism of injury, ASA
score, AO fracture type and pre-fracture ambulation scores of both
groups were detailed in Table 1. No significant difference was
observed between groups regarding demographics and fracture
characteristics.
In the manual traction group, there was a significant time gain
in respect of the positioning and preparation period from the end of
anaesthesia to the start of the surgery. Mean duration of
preparation was calculated as 18.0 1.6 min in MT group, whereas
29.0 2.4 in TT group. In MT group, the surgery was seen to have
started approximately 11 min earlier (p < 0.05) (Fig. 3). Regarding
surgery time, despite a delay of approximately 5 min in the manual
traction group, no statistically significant difference was observed. In
terms of total anaesthesia time (Preparation + surgery) approximately 6 min of difference was observed in favor of MT group
(72.8 14.0 min for MT and 78.6 6.5 min for TT, [p < 0.05])
(Fig. 4). The fluoroscopy times of both groups were similar
(Table 2). When fluoroscopy time was evaluated according to the
Table 1
Patient demographics and fracture characteristics.
Gender (male)
Age (yrs)
Side (right)
Mechanism of injury
Falling at home
Motor vehicle accident
Work-related
ASA score
AO fracture type
31A2
31A3
Pre-fracture
ambulation score[19]
Manual
traction
(n = 30)
Traction
table
(n = 34)
11 (36.7%)
76.5 10.2
17 (56.7%)
18 (52.9%)
74.8 10.5
21 (61.8%)
23 (76.7%)
3 (10%)
4 (13.3%)
2.5 1.0
23 (67.6%)
9 (26.5%)
2 (5.9%)
2.4 1.2
9 (30%)
21 (70%)
7.0 1.2
16 (47.1%)
18 (52.9%)
7.2 1.3
Fig. 4. Graph showing the difference between total anaesthesia time.
AO fracture type, fluoroscopy time tend to be longer in 31A3 multifragmented per-trochanteric fractures (3.74 0.9 min) compared
with 31A2 intertrochanteric fractures (3.2 0.5 min). The difference
observed between 31A2 and 31A3 fractures was not statistically
Please cite this article in press as: Şahin E, et al. Traction table versus manual traction in the intramedullary nailing of unstable
intertrochanteric fractures: A prospective randomized trial. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.04.012
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Table 2
Details of surgical data.
Manual
traction
(n = 30)
Operative time (min)
Preparation (anaesthesia-incision)
Surgery (incision-wound closure)
Total anaesthesia time (min)
(anaesthesia-wound closure)
Fluoroscopy time (min)
Blood loss (ml)
Number of assistants
Traction
table
(n = 34)
P-value
18.0 1.6
29.0 2.4
P < 0.05
55.1 13.4
72.8 14.0
49.8 4.9
78.6 6.5
P = 0.426
P < 0.05
3.6 1.0
202.3 23.7
2 (1 3)
3.4 0.5
195.2 11.3
1 (1 2)
P = 0.918
P = 0.358
P < 0.05
significant. Also no significant difference can be demonstrated
according to method of traction. The amount of blood loss was
similar in both groups. In the comparison of the number of assistants
participating in the surgery, the mean number of assistants needed in
the traction table group was seen to be lower. Median number of
assistants were two assistants (1 3) in MT group and 1 assistant
(1 2) in TT group (p < 0.05) (Fig. 5). (Table 2)
In radiological evaluation of the reduction quality in the frontal
and sagittal plane from the radiographs taken on post-operative
day one, in the manual traction group, anatomic reduction was
achieved in 18 (60%) patients, good reduction in 10 (33.3%) and
poor reduction in two patients (6.6%). In the traction table group,
reductions were anatomic in 25 (73.5%), good in eight (23.5%) and
poor in one (2.9%) patient. The differences between groups were
statistically not significant. The power analysis of chi-square test of
data of reduction quality revealed a power of 78% for sample size of
64 for 0.3 effect size.
Fixation quality was evaluated according to the position of the
tip of the head screws within femoral head according to Cleveland
and Bosworth on both sagittal and coronal planes. Central-central
and inferior-central placement of screws at both planes was
accepted as optimal fixation. All remaining positioning of screws
were accepted as suboptimal fixation, from which superior posterior was the worst one. Optimal positioning of screws
was similar at both method of traction. Central-central and
inferior-central placement was achieved in 19 cases (63.3%) from
the MT group and in 21 cases (61.8%) from traction table group. The
rates of screw misplacement, which is accepted as suboptimal
fixation, were also similar between both groups. (Table 3)
In a total of seven patients out of 72 cases, comprising four
patients from the manual traction group and three from the
traction table group, closed reduction could not be achieved and
reduction was made by partially opening the fracture line.
Details of data regarding outcome were detailed in Table 4. None
of the patients in TT group experienced traction table related
complications. The postoperative length of hospital stay was similar
in both groups. In the early postoperative period, superficial
infection developed in a total of three patients; two from the
manual traction group and one from the traction table group. All
these patients were successfully treated with wound care and
antibiotics. None of the patients developed deep infection necessitating revision with implant removal. At 6th month visit, functional
status scores consisting of ambulation scores and Harris Hips scores
were also similar at both groups. Although the ambulation score of
all the patients reduced 1.0 1.2 points compared with the
preoperative status, no statistically significant difference was
determined between the groups in respect of ambulation score
and HHS. Radiological malunion was determined in four patients
from the manual traction group and one patient from the traction
table group. Since none of these malunion cases were symptomatic,
no additional intervention was attempted. (Table 4)
Fig. 5. Graph showing the difference between numbers of assistants.
Discussion
Although traction table provides safe and appropriate patient
positioning, it can also cause loss of time and complications.
Decreasing anaesthetic exposure and operative time is an
important step in surgical treatment of high risk elderly patients.
When the anaesthesia period of elderly patients with additional
comorbidities is prolonged, the complications affecting morbidity
and mortality can develop, such as pulmonary complications, deep
vein thrombosis and infection [24,25].
Cephalomedullary femoral nails can be applied using a traction
table or with manual reduction and traction without using a
traction table. While no studies can be found comparing the use of
a traction table and manual traction in the application of
cephalomedullary nailing in patients with unstable intertrochanteric fractures, there are studies comparing these two traction
methods in intramedullary nailing of femoral diaphyseal fractures.
In a study by Karpos et al., the effects of manual traction and
Please cite this article in press as: Şahin E, et al. Traction table versus manual traction in the intramedullary nailing of unstable
intertrochanteric fractures: A prospective randomized trial. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.04.012
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Table 3
Details of early post-operative radiological evaluations for reduction and fixation
quality.
Quality of reduction
(according to Schipper
et al.[20])
Anatomic
Good
Poor
Quality of fixation
(according to Cleveland and
Bosworth quadrants[21])
Superior-anterior
Superior-central
Superior-posterior
Central-anterior
Central-central
Central-posterior
Inferior-anterior
Inferior-central
Inferior-posterior
Manual
traction
(n = 30)
Traction
table
(n = 34)
18 (60%)
10 (33.3%)
2 (6.7%)
25 (73.5%)
8 (23.5%)
1 (2.9%)
0
2
1
2
16
3
2
3
1
1
2
1
2
19
3
1
2
3
Table 4
Functional and radiological outcome data of post-operative 6th month follow-up
evaluation.
Postoperative hospital stay (days)
Harris Hip Score (6th month)
Ambulation score (6th month)
Superficial wound infection
Radiological malunion (6th month)
Manual
traction
(n = 30)
Traction
table
(n = 34)
8.8 1.5
69.6 6.7
5.8 1.0
2 (6.6%)
4 (13.3%)
8.3 1.0
71.7 8.4
6.2 1.2
1 (2.9%)
1 (2.9%)
traction table were examined on operating time in cephalomedullary nailing in femoral diaphyseal fractures. It was reported that
the anaesthesia period was approximately 33 min shorter with
manual traction [26]. Similarly, Stephen et al. [12] made a
prospective, randomized comparison of the two methods of
traction in femoral nailing revealing a shorter total operating
time in favor of manual traction. Wolinsky et al. [27] also reported
that the use of a traction table caused a loss of time and manual
traction was a much more rapid method. In the current study, the
preparation time for surgery (positioning from anaesthesia
application to starting the incision, cleaning, draping) of the
patients in the manual traction group was significantly shorter
than that of the traction table group. Surgery was started in the
manual traction group with a time-saving of approximately
11 min. Intra-operatively some loss of time is expected for
achievement and maintenance of reduction in manual traction
group, since reduction was achieved and maintained before
incision in TT group. This theory did not translate to surgical
data. Although there was approximately 5 min of loss of time in the
mean surgery time in the manual traction group, the difference
between groups did not reach statistical significance (p = 0.426).
When total anaesthesia time was analyzed, which is the sum of
preparation time and duration of surgery, approximately 6 min
difference was observed in favor of MT group (p < 0.05) (Table 2).
The difference observed in current study was less than previously
reported studies regarding femoral intramedullary nailing. The
reason for such difference can be contributed to the factors related
with difference in surgical technique (femoral diaphyseal nailing,
distal locking, etc.). Despite a significant difference of total
anaesthesia time between TT and MT groups, this difference
(6 min) did not translate to outcome and intra-operative anaesthesia related complications. But with large-scale comparative and
prospective outcome studies, such a difference might affect
outcome.
There is a scarcity in the literature regarding the amount of
fluoroscopy utilized during fixation of intertrochanteric fractures.
Some studies reported the amount of fluoroscopy as minutes, some
studies reported as ‘‘shoots’’. This difference complicates the
interpretation and comparison between the results of previous
studies. Zhang et al. reported mean fluoroscopy duration of
3.6 0.18 min in 57 patients operated with traction table. Similarly,
Wu et al. reported the mean fluoroscopy time as 2.9 0.16 using
traction table. Wang et al. reported the fluoroscopy time in 59
patients treated with InterTAN nail using traction table as 16.3 4.4
shoots [28–30]. In current study, duration of fluoroscopy in TT group
was comparable with previous studies. Although shorter fluoroscopy
was expected due to stable positioning and straightforward imaging
with traction table, no statistically significant difference was
observed between the two groups in respect of fluoroscopy time
(3.6 1.0 min in MT group vs 3.4 0.5 min in TT group [p = 0.918]).
Despite similar fluoroscopy time was recorded in both groups,
amount of radiation exposure might be higher in MT group since
operation team is more approximated to patient and C-arm device. To
determine this, potential difference studies utilizing X-ray dosimetry
devices is needed. We also analyzed the fluoroscopy time according to
fracture type according to AO classification. Theoretically, it is
expected to use more fluoroscopy in more comminuted fractures.
Although there was a slight increase in fluoroscopy time in multifragmented AO type 31A3 per-trochanteric fractures, compared with
less comminuted AO type 31A2 intertrochanteric fractures
(3.74 0.9 min vs 3.2 0.5 min, respectively), the difference did
not reach statistical significance (Table 2).
Blood loss is an important determinant of morbidity and
mortality in surgical treatment of hip fractures in elderly [31].
Estimated blood loss during intramedullary nailing of intertrochanteric fractures using traction table, reported in literature
ranged between 70.1 27.7 and 235 124.6 ml [28–30]. In our
study, mean blood loss was 202.3 23.7 ml in manual traction group,
whereas 195.2 11.3 ml in traction table group. The results were
concordant with previous literature and no significant difference
regarding blood loss was observed according to the method of
traction utilized.
In our study, despite positive effect of manual traction method
in terms of reduction of surgical site preparation and anaesthesia
time, this method resulted with significant increase in number of
surgical assistants (Table 2). Number of surgical assistant may be
an important determinant of resource utilization and cost,
especially in developed countries. In a recent multicenter study
about cost analysis of hip fracture cases from Netherlands, surgeon
cost was reported to be between 109 and 143 s per hour [32].
Additionally, increase in number of sterile personnel in operation
theatre also may increase the infection rate [33]. But, in terms of
reduction of anaesthesia period and patients benefit, the circumstances of increased number of surgical assistance can be justified.
Traction table is a successful method of achieving and
maintenance of reduction. When combined with stable, load
sharing and durable fixation with intramedullary devices, successful results can be achieved. When appropriate surgical
technique is utilized, good-anatomic reduction can be achieved
in 83 100% of cases [7,8,34–36]. In current study, good-anatomic
reduction could be obtained and maintained in the vast majority
(total 93.3% MT group, total 97.1% TT group) of cases. Only two
cases in manual traction group (6.7%) and one case in traction table
group (2.9%) revealed poor reduction radiologically. Also anatomical reduction was achieved in 60% of cases in MT group and 73.5%
of cases in TT group. We performed a power analysis revealing a
Please cite this article in press as: Şahin E, et al. Traction table versus manual traction in the intramedullary nailing of unstable
intertrochanteric fractures: A prospective randomized trial. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.04.012
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rate of 78% for the study sample size for 0.3 effect size. Although
difference in number of poor reduction cases is two-fold, the
statistical difference between two groups did not reach significance. To increase power rate of this analysis to 98.7%, sample size
was calculated to be 320. Further studies should take this point
into consideration for determination of sample size. With largescale studies focusing on reduction quality, this significance can be
demonstrated.
There are some methods evaluating the fixation quality of hip
fractures, including Tip-Apex-Distance and Cleveland-Bosworth
quadrants. Since there is a close resemblance of orientation of neck
screws in InterTAN nailing with DHS screw, we used Cleveland
Bosworth quadrants method for fixation quality. According to this
method, central-central and inferior-central positioning is accepted as optimal fixation. Turgut et al. [37] achieved optimal fixation
in 53.5% of cases using PFN-A as the fixation device in a study
reporting intramedullary nailing in lateral decubitus position with
manual traction. In our study at 63.3% of cases in MT group and
61.8% of cases in TT group, optimal fixation was achieved. We also
did not find any relation with suboptimal fixation and fixation
failure (Table 3).
Hospitalization period is commonly influenced by comorbidities, cognitive and functional capabilities of the patient. Mean
hospital stay of intertrochanteric fractures treated with intramedullary nail fixation ranged between 21.7 to 8.03 days in previous
studies [19,28,38]. In our study mean hospitalization durations
were 8.8 1.5 and 8.3 1.0 days for MT and TT groups, respectively.
No significant difference was observed according to the method of
traction.
At 6th month follow-up, ambulation scores according to Palmer
and Parker were similar in MT and TT groups as 5.8 1.0 and
6.2 1.2, respectively. Harris Hip Scores were also similar as
69.6 6.7 in MT group and 71.7 8.4 in TT group. Overall,
complication rates were also similar between two groups
(Table 4). We also did not encounter any complication related with
traction method used. It was previously concluded in a review by
Butler et al. as; functional recovery in intertrochanteric fractures in
elderly was not related with fracture type and implant used, rather
influenced by age, pre-fracture functional and cognitive status [39]. In
this study, functional results observed at both groups were
comparable with previously reported studies [28,38,40].
In this study, we observed only 11.1% loss of follow up rate, which
increased the quality of the study. There are some limitations in our
study. Functional evaluations of some cases with impaired cognitive
status were made by interviewing with a relative or a caregiver
involved with the principal care of the patient.
Conclusions
Manual traction and traction table facilitated intramedullary
fixation of intertrochanteric fractures revealed similar results.
Intramedullary nailing for unstable intertrochanteric femoral
fractures could be performed by both methods effectively and
safely. However, manual traction reduced the preparation time
and total anaesthesia duration, despite an increase in number of
surgical assistant.
Conflicts of interest
None declared.
Acknowledgments
Authors wish to thank Dr. Mustafa Cagatay BUYUKUYSAL for his
contribution on the statistical analyses of the study.
7
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